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How Providers Across the US Are Caring For the Country’s 580,000+ Homeless People

More than 580,000 individuals are experiencing homelessness in the U.S., and hospitals across the country have dedicated programs to caring for this incredibly at-risk population. The indicatives at UCLA Health, Boston Health Care for the Homeless Program and University of Illinois Health focus on street medicine, connecting patients to housing and integrating behavioral and preventive care into primary care.

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In a fee-for-service world, it can be hard for health systems and other providers to prioritize caring for homeless patients, who carry some of the worst health risks in the country. Still, some providers maintain it is an important part of their work.

More than 580,000 individuals are experiencing homelessness in the U.S. today, and hospitals across the country have dedicated programs to caring for these incredibly at-risk people.

Earlier this year, Los Angeles County declared a state of emergency related to its  70,000 unhoused people. County officials made the declaration so that more resources can be allocated to organizations working to address this issue.

On the first of this month, the UCLA Health Homeless Healthcare Collaborative announced that it had received a $25.3 million two-year grant from the state of California to expand its street medicine program.

Originally made possible through philanthropic support, the program began in January 2022 with two mobile health vans, said Brian Zunner-Keating, the collaborative’s director, in a recent interview. The vans travel to homeless encampments and shelters to provide people with free healthcare that takes many forms — preventive care, primary care, medical screenings, urgent care and referrals to social services. 

“A big part of what we do also is disease screening and treatment. One of the most common diagnoses that we’re seeing is undiagnosed and untreated high blood pressure, so it’s something we try to be acutely aware of,” Zunner-Keating declared. “We do an assessment, provide medications if appropriate, and then follow up with them to see how they’re doing and adjust their care plan if needed, as well as their medications, as we go.”

Last year, UCLA’s vans recorded 6,000 encounters with homeless patients and delivered medications more than 1,500 times. Later this month, UCLA is adding a third mobile health van to its fleet. Three more vans will be added sometime this year, Zunner-Keating said.

The collaborative will use its new funding to develop and implement a records management and communication systems that will allow UCLA’s and other street medicine teams to coordinate care provided to the area’s homeless population. Having this system in place will be important for the continuity of care, Zunner-Keating pointed out.

He also said that UCLA will use some of its funding to explore how it can expand access to specialty care services for homeless people.

“That’s a huge gap that’s been identified. There are a number of street medicine teams and other providers that are providing primary care services out in the community, but specialty care is still really hard to get,” Zunner-Keating explained.

He encouraged other urban healthcare providers to establish street medicine programs for their city’s homeless people, as meeting patients where they are is especially important for this population. 

The Boston Health Care for the Homeless Program (BHCHP) is very aware of this fact and has been focused on serving patients out in the community for decades. The private nonprofit was established in 1985 and as a demonstration project under the Robert Wood Johnson Foundation.

No longer funded by the foundation, BHCHP is now a federally qualified health center with 600 employees, said Barry Bock, who recently stepped down as BHCHP’s CEO and now serves as special liaison to the CEO. The organization “relies really heavily on philanthropic giving” but also has contracts with Medicaid and accountable care organizations, he explained.

BHCHP cares for roughly 11,000 patients each year using a primary care model that prioritizes addiction care and mental health services. The FQHC operates out of a large medical facility with 104 inpatient respite beds, two pharmacies, a dental practice and an ambulatory clinic. But many of BHCHP’s care interactions happen on the street or in shelters, Bock pointed out.

He said that homeless healthcare requires care teams to go out in the community so they can learn about which health risks are most prevalent and quickly address them. A key example of this occurred in 2019 when BHCHP noticed a meningitis outbreak among Boston’s homeless residents.

Immediately after becoming aware of the problem, BHCHP began contract tracing people who had recently stayed in the city’s shelters. The organization gave preventive antibiotic treatment to more than 100 people it identified as having been exposed to the virus.

BHCHP was so instrumental in slowing the spread of this disease that the Centers for Disease Control and Prevention reached out to the organization to learn about the tactics they used to help stop the outbreak, Bock said. He attributed much of BHCHP’s success to its ability to have its finger on the pulse and act quickly — most of the prophylaxis antibiotics the organization administered were given on the same day it found out about the outbreak.

“Healthcare should recognize the needs of the community,” Bock declared. “And there should be health care that transforms itself to meet those needs. I think that’s what our program has done really well, and our patients and the community in general have really taught us about how to make those kinds of pivots and innovations to meet the changing needs of the community.”

Stephen Brown, the senior director of social behavioral health advocacy at University of Illinois Health in Chicago, agreed with Bock’s statement. He said he is a firm believer that homelessness should be framed as a public health issue, not a social issue.

Homeless people on average live 27 years less compared to those who have a place to stay, Brown pointed out. Many deaths among people experiencing homelessness are a result of being exposed to dangerous weather conditions for long periods of time, leading them to contract diseases like pneumonia and frostbite.

Brown is currently building a dashboard to get a better understanding of weather-related illness and death among Chicago’s homeless residents. When Chicago had a cold snap in December, his team identified 12 individuals that died from cold exposure.

“It’s never been published before, so I am collecting that information. And we are going to be publishing that on a dashboard so that it becomes publicly available, and this is important for policy reasons. There are policy implications to help guide where our limited resources go and that’s the primary reason why I’m developing this dashboard,” he declared.

Brown is also involved in UI Health’s Better Health Through Housing program, which began in 2018. The health system launched the program to help patients who frequently visit the emergency department. These patients are usually poor and suffer from chronic conditions like heart failure, kidney disease, mental illness and addiction. A significant chunk of these patients, who account for a disproportionately large amount of the emergency department’s costs, are also homeless.

Working together with nonprofits, managed care organizations, the county and the city, UI Health has attracted more than $20 million in funding and housed more than 100 people through this program.

“We’re not doing this for economic reasons. We’re not doing it for revenue. More hospitals would get involved if more insurance companies or the state or Medicaid would begin to pay for the housing of these individuals. Because we can demonstrate a pretty significant reduction in ER spend, and their health improves once you put them in a house. We recognize and understand that homelessness is a health issue, but we need more engagement at the state level, the Medicaid level and with insurance companies,” Brown declared. 

He thinks the need for local governments and payers to increase their involvement in homeless healthcare is urgent. Hospitals are well aware of all the health risks that the homeless population faces, but it’s hard for them to address this issue because they don’t get paid for that care, Brown said.

Photo: 400tmax, Getty Images

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